Social/developmental History Form Page 2
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3DEVELOPMENTAL HISTORY:
Birth history:
Age of mother when pregnant
______
Child was:
___
full term
Did mother receive prenatal care
Yes
No
uncomplicated labor
Complications during pregnancy
difficult delivery
Premature by
weeks
breech position
Child’s birth weight
forceps used
Birth Injury or complications at birth
Cesarean section
Developmental History: Give the approximate age when your child:
First began to crawl
Was toilet trained during the day
First walked independently
Was toilet trained during the night
Began using single words
Could feed self independently
Began using understandable phrases
Put on/took off clothing by self
Was your child difficult to care for in infancy? (explain)
Was feeding/eating a problem?(explain)
Was coordination a problem?(explain)
When were you first concerned there could be a problem?
Other concerns about your child’s development?
MEDICAL AND MENTAL HEALTH HISTORY:
Has the child ever had problems with or needed:
Glasses/had vision difficulties
Asthma
Hearing difficulties/hearing devices
Seizures (explain)
Chronic ear infections
Allergies (explain)
Ear tubes
Orthopedic braces (explain)
Specific Medical Diagnoses:
Cerebral Palsy
Brain Injury (explain)
Down’s Syndrome
Hospitalizations (explain)
Autism
Other (explain)
List all medications the child takes:
Medication
Purpose
Dosage
Times per day
How long on medication?
List physicians/clinics involved with child:
Physician/Clinic
Address
Area of Specialty
Has the child received counseling or had a psychological evaluation at a hospital, mental health center?
Name of counselor/psych
Clinic/facility
Date(s)
Reason for treatment/evaluation
List names of programs and people that have worked with or are currently working with the child (such as speech,
OT, PT, etc.)
Name of Program
Type of Service
Name of therapist/provider
Date(s)
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